Rise in C-Sections Is Stirring Worry

The rate of babies delivered by cesarean section in New York City increased to 30.6%, in 2006, up from 29.7% in 2005, in a trend that some politicians, doctors, and women's health advocates say is cause for concern.

The citywide increase reflects a national upward trend in the number of cesarean deliveries in recent years. Last month, the Centers for Disease Control and Prevention reported that the national cesarean rate in 2006 reached a record high, 31.1%, according to its preliminary birth data for that year.

"There is alarming concern throughout the country that there are too many cesarean sections," said Public Advocate Betsy Gotbaum, who in 2006 released a report based on 2005 data detailing individual hospitals' cesarean section rates. "It's additional cost and it's additional risk," Ms. Gotbaum said, adding, "I hate to impart motives on hospitals and doctors … I can just tell you the numbers speak for themselves."

"It's clearly been rising," the head of obstetrics at Brooklyn's Lutheran Medical Center, Dr. Iffath Hoskins, said. "On a day-to-day basis, there will be three or four cesareans going on at a given time," she said, estimating that one in three deliveries at Lutheran results in a cesarean.

A sampling by The New York Sun of New York City hospitals shows there are still disparities in cesarean rates among individual hospitals. At St. Luke's-Roosevelt Hospital, the rate in 2006 was 26%, up from 25% in 2005. At NYU Medical Center, the rate was 31% in 2006, down from 32% the year before.

NewYork-Presbyterian Hospital reported a 35.4% cesarean rate in 2007 for its three campuses, down from 37.1% in 2005.

North Central Bronx Hospital had one of the lowest cesarean section rates, nearly 20%, in 2007, up from 17.3% in 2005. In large part, the relatively low rate is a result of the hospital's reliance on midwives and the medical staff's preference for vaginal deliveries, the hospital said. "If there are any complications with the baby, a cesarean section is performed without hesitation," the hospital's director of midwifery, Susan Papera, stressed.

To some, cesarean sections are a revenue stream for hospitals.

According to the most recent costs available from the group Childbirth Connection, the average charge for a cesarean section delivery in a hospital is $12,578. The charge for a vaginal delivery is $6,724.

"It's more costly for the hospital because you need anesthesia, you need more nursing, the patient stays extra days," Dr. Hoskins, said. "It's far more labor intensive and financially expensive if a woman has a cesarean."

Individual doctors said they are not making more money when they perform cesarean sections. "If anything, I want to get paid more for a normal delivery. It takes much longer. For me, it's much more stressful to attend labor than to do a cesarean section," the director of labor and delivery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, Dr. Amos Grunebaum, said.

The overall increase in cesareans has also been triggered by the changing perception of cesareans among women.

"There's such a relaxed attitude about induction and c-sections that it's not considered risky anymore," the president of the group Choices in Childbirth, Elan McAllister, said.

She said women were getting a message from their peers and from their doctors that vaginal delivery is dangerous, while cesareans are more civilized. "A lot of women today are career women who are used to being in control, so the idea of being able to micromanage their birth is appealing," she said.

Some doctors warned that such an attitude and the simultaneous rise in cesarean rates presented a health risk for women.

"It's concerning because there are a number of risks to having a cesarean delivery. You're having surgery," a fellow of the New York chapter of the American College of Obstetricians and Gynecologists, Dr. Ashlesha Dayal, said.

Some say it's not the women choosing caesarians but doctors aiming to avoid complicated childbirths and possible malpractice lawsuits.
"Obstetricians fear malpractice litigation," the acting chairman of obstetrics at North Central Bronx Hospital, Dr. Wayne Cohen, said.

Even as the number of cesarean sections is up, some women's groups are promoting "natural" childbirth as an alternative. Last week, a documentary directed by Abby Epstein and produced by former talk show host Ricki Lake called "The Business of Being Born" opened at the IFC Center.

The executive director of Friends of the Birth Center, the group behind a proposal to open a new $7 million birthing center in Manhattan, is Rebecca Benghiat. So far, the group, whose plan is still in its nascent stages, has secured a 7,000 square foot space on West 30th Street. "Even if you don't know what the rate should be, you know what's going on is too high. People's sense is that it's not right," Ms. Benghiat said.

Looking forward, the rising cesarean rates may also create a shortage of facility space.

The average length of stay after a cesarean section is double that of a vaginal delivery. "It's creating capacity issues," said Thomas Guglielmo, the director of a New York-based healthcare consulting firm, Tefen USA. Mr. Guglielmo said hospitals are spending millions on expansion projects.

Montefiore Medical Center in the Bronx recently updated the obstetrics and gynecology facilities on its Weiler campus, and NewYork-Presbyterian is planning to upgrade some of its obstetrics units in the near future to include more single rooms and more amenities.